the number of patients receiving permits for referrals to hospitals in
Israel - or the PA or Jordan - increased by 45 percent from 4,932 in 2006 to
7,176 in 2007, and continued to increase in the first six months of
2008....At the same time, there have been at least 20 incidents where
Palestinians used medical missions to attempt terror attacks.

[Dr. Aaron Lerner - IMRA:

While the Foreign Ministry invests in "branding" Israel sharing information
with the world about Israel technology and bikinis, it is nice to see the
kind of job that can be done presenting information that specifically
addresses concerns raised about Israel within the context of the Arab
Israeli conflict.]

Israeli Approvals for Medical Entry in the Shadow of Terror Attacks at the
Erez Crossing
Elihu D. Richter MD, MPH JCPA No. 567 1 October 2008
For graphs and charts:
www.jcpa.org/JCPA/Templates/ShowPage.asp?DRIT=2&DBID=1&LNGID=1&TMID=111&FID=283&PID=0&IID=2649&TTL=Israeli_Approvals_for_Medical_Entry_in_the_Shadow_of_Terror_Attacks_at_the_Erez_Crossing

For several years, the Rapporteur to the UN Commission on Human Rights (now
the UN Human Rights Council) and human rights groups have criticized the
Israeli government and health care system for denying access to Gazans
seeking to receive permits for care in hospitals in Israel, the PA and
Jordan. Yet the data shows that the number of patients receiving permits for
referrals to hospitals in Israel - or the PA or Jordan - increased by 45
percent from 4,932 in 2006 to 7,176 in 2007, and continued to increase in
the first six months of 2008. These trends occurred despite a decline in
entry approval rates, mostly because of security reasons.

The facts are that Israel has provided ever increasing numbers of approvals
of permits since the Hamas takeover of Gaza, despite increasing rocket
attacks on Israel's civilian population, including mortar and terror attacks
directed at the Erez crossing used by patients.
The premise that guides medical ethics is that there should not be even one
death from delay, but sometimes the delays were related to problems of
availability of beds, and at other times to security concerns. There were
cases in which patients' deaths or complications were attributable to
delays. But in other cases, deaths and complications were attributable to
efforts to transfer to Israel critically ill or near terminal patients from
Gaza whose care was deemed as bothersome or too costly.
The longer term solution to the problem of delays associated with referrals
is to promote medical capacity-building in Gaza's hospital and health care
systems so that patients should not have to travel elsewhere for critical
care.
The mandate of the Rapporteur to the UN Commission on Human Rights has so
far been restricted to reporting only on violations of human rights to life,
safety, and access to health care of members of one national group,
Palestinians, but not members of another group, Israelis. The result is a
selective concern with the human rights of one that ignores assaults on the
human rights of the other.

Background
Since the Six-Day War in 1967, Gazans have been coming to Israel for medical
treatment and for training in many Israeli hospitals, including Hadassah in
Jerusalem, Ashkelon, Tel Hashomer, Beersheva, and others. With
implementation of the Oslo accords in 1994, the Palestinian Authority
reduced access for training and referrals for care as it sought to increase
reliance on its own health care system, but in recent years, there has been
a tendency towards increased patient referrals to Israeli hospitals.1 Even
so, for several years, human rights groups - notably Physicians for Human
Rights-Israel (PHR-I), the UN Commission on Human Rights (now the UN Human
Rights Council), and World Health Organization (WHO) agencies - have
criticized the Israeli government and health care system for denying access
to Gazans seeking to receive permits for care in hospitals in Israel.2,3
To examine the validity of these criticisms and their context, we tracked
trends (January 2006 to June 2008) for approved permits and reported deaths
in individual patients. In parallel, we tracked trends during the same
period for rocket, missile, and terror attacks targeting the Erez crossing,
through which Gazans enter Israel.

Methods
Our data came from WHO, PHR-I, the Israel Defense Forces (IDF) medical
liaison office with Gaza in the office of the Coordinator of Government
Activities in the Territories (COGAT), and the Israel Security Agency (ISA,
formerly the General Security Service - Shabak).
We prepared two parallel timelines. One tracked the number of approved
permits, based on data from COGAT and verified by WHO (through December
2007). The other timeline tracked Kassam rocket and other attacks from Gaza
directed against Israeli civilian populations, notably in Sderot and
Ashkelon, based on sources tracking terror attacks on Israel.4
The Palestinian Authority decides whether Gazan patients receiving approval
for medical care in Israeli hospitals are treated there, or in Palestinian
hospitals in eastern Jerusalem or the West Bank, or in Jordan. The decision
as to where to refer is heavily influenced by the fact that the cost of care
is substantially higher in Israeli hospitals and the PA covers these costs.
We also reviewed relevant PHR-I and ISA documents on patients denied access
to medical care in Israel and deaths, as well as on terrorists disguised as
patients.

Trends in Approvals for Patient Referrals
The data showed that patients receiving permits for referrals to hospitals
in Israel - or the PA or Jordan - increased by 45 percent from 4,932 in 2006
to 7,176 in 2007, and continued to increase in the first six months of
2008.5
Sources: COGAT and WHO, Jerusalem Office 2008. Data from Jan. 2008 ff not
yet confirmed by WHO.

Although there were fluctuations, the mean rates of permits per month in
these three years were 411, 598, and 733 respectively. Table 1 shows that
the approval rates among those applying were 90.2 percent in 2006, falling
somewhat to 81.5 percent in 2007 and even more sharply to 66 percent in
2008. The substantial increase in approved permits more than offset the
increase in percentage of refusals - from 18 to 34 percent. Throughout the
entire period, a much smaller number of Gazans received approval for care in
Egypt.

According to COGAT spokesman Peter Lerner, no patient is moved from Gaza to
the Erez crossing and evacuated to Israel, the PA, or Jordan until Gaza
physicians report that he or she has been stabilized. For patients with
critical care problems who are suspected security risks, the ISA decides
what to do, without necessarily consulting a doctor (see below). According
to Professor Rafael Walden, Head of Vascular Surgery at Tel Hashomer
Hospital and a senior consultant to PHR-I, the increase in requests for
referrals resulted from system-wide breakdowns in the infrastructure of
medical care in Gaza (see below). Doctors from PHR-I who visited Gaza in
recent months reported severe shortages of basic equipment, replacement
parts, broken equipment, and shortages of medications, which they attributed
to security and political closures. As terror attacks increased following
the Hamas takeover, security concerns were the major reason for the increase
in the number of refusals.
Nearly all referrals were for medical conditions other than traumatic
injuries, except for June 2008 when there was an abrupt increase in
referrals of Palestinians injured in factional fighting between Hamas and
Fatah, and again in early August, when more Gazans fled into Israel.

Trends in Rocket Attacks and Other Acts of Terror Against Israeli Civilians
The foregoing trends in increased approvals occurred despite the Hamas
takeover, the Second Lebanon War, the kidnapping of IDF soldier Gilad
Shalit, and an increase in rocket and mortar fire from Gaza. In the weeks
leading up to an informal ceasefire in June 2008, attacks on the border
crossings through which patients had to pass could have been another factor
explaining much of the recent drop in applications and approvals of permits
(see Figure 1).
Since the Israeli disengagement from Gaza in the summer of 2005, Hamas and
its allies have fired more than 6,000 rockets and mortars into Israel.6 The
number of rocket attacks increased from November 2007 onward, targeting
Sderot and other civilian areas. Palestinian terrorists fired some 200
mortar shells and Kassam rockets at the Erez crossing between Israel and
Gaza, resulting in substantial damage and injuries to personnel.
During this period there were some 30 foiled attempts at terrorist
infiltration, including at least 20 incidents where Palestinians used
medical missions to attempt terror attacks. In June 2006, a female suicide
terrorist was arrested at the Erez crossing while on her way to carry out an
attack on an Israeli hospital. In May 2007, two female bombers received
permits but were caught after slipping through security checks.7 On May 22,
2008, a truck loaded with 4.5 tons of explosives exploded just before
reaching the crossing.
The ISA published reports on 11 individuals, including those just cited, who
used permits for medical care or for family visits to patients already in
Israel for the purpose of carrying out terror-related activities. At Erez,
three patients admitted under questioning that they had purchased referral
notes with bogus medical information from doctors in Gaza. According to the
ISA, terror organizations were making a special effort to recruit women,
including those who are pregnant, who are less likely to be closely examined
and whose heavy clothing more readily conceals suspicious objects.8 PHR-I
forwarded these patients for approval, unaware of their true status.

Reports of Delays and Deaths
In 2008, WHO and PHR-I published a spreadsheet itemizing details on 32 Gazan
patients whose deaths were attributed to delays in processing requests for
medical care in Israel and refusals of permits during the period October 1,
2007 to March 1, 2008.9 These months were a peak period for rocket and
mortar attacks on Israel, many specifically directed at the Erez crossing (a
fact not cited in the WHO/PHR-I report). The report is based on interviews
of the families of patients who applied for permits during this period and
examinations of their medical records.
Ten of the 32 patients did not receive permits for security reasons. Three
were denied permits at Rafah, the gateway from Gaza controlled by Egypt. In
five cases, the delay was attributed to lack of available vacant beds - a
severe problem in Israel's overburdened health care system. In one case, a
patient reported by PHR-I as dead from lack of treatment was found to be
alive in Gaza, and in other case, a patient reported as dying from cancer as
a result of non-referral was actually treated in Israel and returned home
before dying. One male, aged 21, was reported as having stomach cancer, and
another was a 68-year-old female with liver cancer, conditions for which
referral would do little to alter a dismal prognosis. Four infants under one
year old and one child under the age of 5 were among those whose deaths were
attributed to delays or non-receipt of permits.
In July 2007, there was an outbreak of violence between Hamas and Fatah
leaving 170 dead and hundreds of others injured from gunshot wounds.
Following this violence, PHR-I presented evidence of delays in providing
access to care and subsequent death of 3 individuals and loss of limbs in 4
others, and published a letter by Professor Rafi Walden, Head of Vascular
Surgery at Tel Hashomer, in support of a petition to the Israeli High Court
of Justice demanding the opening of the crossings to the sick and wounded,
and the provision of entry permits for 26 patients in urgent need of medical
care in Israel.10 The Court, distinguishing between danger to life and
danger to limb, rejected the petition.
The facts are that Israel has provided ever increasing numbers of approvals
of permits since the Hamas takeover of Gaza, despite increasing rocket
attacks on Israel's civilian population, including mortar and terror attacks
directed at the Erez crossing used by patients.

Is Israel Meeting Its Obligations to Provide Access to Medical Care for
Gazans?
Israel totally withdrew its military and civilian presence from all of Gaza
in 2005 and no longer occupies the territory.
The robust upward trend in approvals for referrals occurred despite the
sharp rise in Kassam rocket attacks from Gaza and a four-fold increase in
the nationwide death toll from terror attacks inside Israel in 2008 (28 in
the first six months compared to 13 in all of 2007).11

Has Hamas Met Its Obligations to Respect the Erez Crossing as a Medical
Sanctuary Protected from Terror Attacks?
Sadly, the question to be asked is whether Hamas' repeated attacks on the
Erez crossing, which place both providers and patients at risk, are war
crimes or crimes against humanity as defined by the UN Charter.

Have Delays in Approvals for Referrals Resulted in Deaths of Patients?12
The premise that guides medical ethics is that there should not be even one
death from delay. The position of PHR-I is that inserting security checks
into the medical decision-making process introduces delays which endanger
life and limb, and therefore violates the core values of medical ethics. The
spokesperson for COGAT has declared that Israeli policy is that everyone
from Gaza, including those who are security risks, are entitled to
treatment, if not in Israel, then in the PA or Jordan.
Concerning the 32 cases in which deaths occurred allegedly following denial
of entry permits, in how many was there a cause-and-effect relationship
between delay and loss of life? Clearly, in some cases, loss of life or limb
occurred as a result of delays, but sometimes the delays were related to
problems of availability of beds, and at other times to security concerns.
In others, we have to ask whether referral would have made a difference
between survival and death beyond acute palliative relief. Information is
not available on how many cases involved efforts to transfer to Israel
critically ill or near terminal patients from Gaza whose care was deemed as
bothersome or too costly - a practice known to anyone familiar with everyday
hospital care everywhere.
Assigning a doctor to be on call to the team at the Erez crossing - a
recommendation of PHR-I - is very sensible,13 but this arrangement cannot be
expected to eliminate the need for security checks - which were introduced
by security authorities following the infiltration attempts of women
patients with bombs strapped to their bodies. The longer term solution to
the problem of delays associated with referrals is to promote medical
capacity-building in Gaza's hospital and health care systems so that
patients should not have to travel elsewhere for critical care. To achieve
this objective, COGAT has made approaches to WHO and to donor countries to
fund capacity-building in the Gaza Strip for treatment and training of
Palestinian personnel, and to facilitate access of foreign expertise to
engage in this capacity-building.14 The definitive solution is for Gazans to
stop the terror which necessitates the security checks and condemns them to
living in a huge prison of their own making.

Allegations of Coercive Pressures on Patients
PHR-I has charged that the Israel Security Agency was using the threat of
not granting approval for medical permits to coerce Gazans into supplying
intelligence information to Israel.15 What are the true facts? What are the
ethical issues?
There is no question that the use of coercion in a medical setting to
extract security information is in conflict with established medical codes
of ethics. But are the ethical issues surrounding non-coercive interrogation
as simple and straightforward as suggested in a brief on ethics attached to
the PHR-I document on delays in care?
We were not in a position to verify or refute these charges, which are based
on information in filmed interviews of Gazans in Gaza. Can we be certain
that the statements of those who were filmed were not influenced by threats
from Hamas, which has established a regime based on intimidation?

The Ethics of Providing Health Care to Patients and Protecting Providers at
the Erez Crossing
The right to life and safety is the most elementary of all human rights. The
first responsibility of government is to protect the life and safety of its
citizens. "Security" is a short-hand term for protecting the right to life
and safety of all individual members of the general population, including
those who provide health care. In keeping with these principles,
non-coercive interrogation of many patients to obtain security information
on those who are dangerous would seem to be an elementary precautionary
measure for protecting the right to life and safety, in light of Hamas' use
of patients as suicide terrorists and its terror attacks directed at the
Erez patient crossing.
The interrogations, delays, and refusals at checkpoints are a consequence of
applying the same precautionary principles that guide questioning, frisking,
body checks, and baggage checks at airports, where tens of millions are
forced to endure inconveniences and delay to detect and deter danger from a
tiny number of terrorists. At the Erez crossing, the risks that there will
be a terrorist infiltration are far greater than at airports - by several
orders of magnitude.16
It follows that the state authorities have to do everything possible to foil
and deter terrorists who have medical permits, given the catastrophic
consequences of failure. Equally true, PHR-I and WHO should be fostering
initiatives to hold organizations accountable for attacking and sending
suicide terrorists through the Erez crossing. Such actions are crimes
against humanity. So far, the postures of PHR-I and the regional WHO office
have been those of silent bystanders to these attacks.

Medical Care Provided to Palestinians by Israel
Nationwide, Israeli hospitals provide a large amount of medical care to
Palestinians. For example, many Palestinian patients are treated at the two
Hadassah hospitals in Jerusalem (Mt. Scopus and Ein Kerem), even though the
Palestinian Authority does not routinely approve coverage for care at
Israeli hospitals. Annually, approximately 123,000 Palestinians are treated
at Hadassah, including 15,000 hospitalizations totalling 67,000
hospitalization days annually, as well as 32,000 visits to emergency
rooms.17
Since the second Intifada, beginning in September 2000, Hadassah Medical
Organization has subsidized care for uninsured Palestinians and has been
committing $3 million a year for treatment, reducing fees by over 50 percent
for those in need or waiving them altogether. These outlays occurred even
though the hospital had to cover the added costs in equipment, supplies and
longer hospitalization imposed by mass terror attacks.
Large-scale access to care for Palestinians from the West Bank and Gaza in
Israeli hospitals predates complaints of PHR-I and WHO. In addition, Israeli
concern for public health and medical care in Gaza predates WHO reports, and
indeed goes back to when Gaza was under Israeli military occupation. During
this period, infant mortality fell to levels lower than in Egypt, polio was
eradicated, and Gazans enjoyed the economic benefits of being linked to the
Israeli economy. Medical scientists from Gaza participated in regional
research projects in tropical medicine and control of environmental
problems.18 WHO was not especially active in these projects, which were
funded by the Israeli government, the U.S., the EU, and third-party donors.

Has the UN, Including WHO, Served as an Objective Monitor?
Statements by the UN Commission on Human Rights on access to health care in
Israel for Gazans, later repeated by WHO, offer a selective and misleading
view of what is happening on the ground. These statements ignore the
increase in absolute numbers of approvals. They also ignore the facts
concerning terror attacks on the Erez crossing.19
But more fundamentally, the mandate of the Rapporteur to the UN Commission
on Human Rights is restricted to reporting only on violations of human
rights of members of one national group, Palestinians, but not members of
another group, Israelis. The result is a selective concern with the human
rights of one that ignores assaults on the human rights of the other. This
selective focus is inherently at variance with the core principles of human
rights, which are based on respect for the life and dignity of all.
* * *
Notes
* I wish to thank my colleagues Professors Elliot Berry and Ted Tulchinsky
of Hebrew University-Hadassah School of Public Health and Community
Medicine, Dr. Nili Ramu and Professor Rafi Walden of Physicians for Human
Rights-Israel, and Peter Lerner, Spokesperson for the Coordinator of
(Israeli) Governmental Activities in the Territories (COGAT) for their
comments and critiques. But the responsibility for the information and
opinions in this document is mine.
1. Prof. Ted Tulchinsky, former director of community health services,
Israel Ministry of Health, personal communication.
2. Professor John Dugard, formerly Special Rapporteur for Palestinian
Occupied Territories of the UN Human Rights Council, published a report to
the Fifty-Eighth Session of the United Nations Commission on Human Rights of
18 March 2002 (WHO Geneva website). See also Professor John Dugard,
interview in the Bridges issue on Health and Human Rights (Sept.-Oct., 2007)
and follow-up rebuttal by T. Tulchinsky, E.D. Richter, and R. Shterkshall,
in Bridges -January-February 2008. Professor Richard Falk, his designated
successor, has repeated Dugard's statements. See "Eviscerating Gaza," Sky
News, http://www.playgroundsforpalestine.net/news.php?ID=25
3. J. Siegel, "Bogged down by politics, Palestinian and Israeli doctors fail
to agree on how to cure Gaza health woes," Jerusalem Post, December 11,
2007.
http://robhom.genios.de/r_sppresse/daten/presse_jpst/jpst.20071211.html
4. Intelligence and Terrorism Information Center, Anti-Israel Terrorism in
2007, and Its Trends in 2008, May 2008.
5. At the time of writing (Aug. 2008), according to the Coordinator of
Government Activities in the Territories (COGAT), Palestinian estimates for
Jan. 2008 to June 2008 for approved referrals are reportedly some 10 percent
less than the figures presented herein. Even with the latter estimates, the
upward trend is unchanged.
6. Ha'aretz, August 11, 2008, http:/haaretz.com/hasen/spages/1010195.html
7. Peter Lerner, the COGAT spokesman who worked at Erez, and experienced
many of these attacks.
8. Israel Security Agency, "Exploitation of Israel's Humanitarian Policy for
Purposes of Terror, http://http://www.shabak.gov.il/ (Hebrew)
9. WHO Office for West Bank and Gaza, "Collective Punishment of the Weakest:
The Urgent Patients," http://www.emro.who.int/.WHO_special_monitoring/
access/access%20to%20health%20services%20(April%20200
10. "Israeli Policies at Erez Crossing, Gaza: Medical-Ethical Position
Paper," http://www.phr.org.il/phr/files/articlefile_1188482807578.doc
11. Wm. Robert Johnston, "Chronology of Terrorist Attacks in Israel Part X:
2006-2008," last updated 3 July 2008,
http://www.johnstonsarchive.net/terrorism/terrisrael.html
12. Similar assessments came from Dr. Ambrogio Manenti, former head of the
WHO office. See WHO Bridges, Jan.-Feb. 2008.
13. Long waits are common in Israel's overburdened hospitals. The author's
wife, having fractured her shoulder in the evening of October 2007, had to
wait 3 hours in the emergency room for x rays, and then another 3 before
being seen by house officers on call, despite the fact that the Professor of
Surgery and Professor of Orthopedics, both colleagues of the author, tried
to expedite matters. Several injured victims of a road accident tied up the
entire staff for many hours.
14. Documentation available from Peter Lerner, personal communication.
15. "Holding Health to Ransom: GSS Interrogation and Extortion of
Palestinian Patients at Erez Crossing,
http://www.phr.org.il/phr/article.asp?articleid=604&catid=42&pcat=42&lang=ENG.
See also "Israel demands Gaza patients be informants,"
http://www.reuters.com/article/homepageCrisis/idUSL31237833._CH_.2400
16. Is it possible to carry out a crude risk estimate of the toll, in human
lives, of failing to apprehend terrorists exploiting humanitarian permits at
the Erez crossing? If the 14 patients receiving permits - out of a total of
some 30,000 who applied (Table 1), had not been foiled on their way to their
terror bombing missions, we could have expected an average of 8 deaths per
each attack, or 112 deaths, based on data on deaths per terror bomb attacks
from the past decade. While everything has to be done to prevent deaths in
all, delays and refusals associated with interrogation - and their deterrent
effect - almost certainly have saved far many more lives than they may have
been related to deaths.
17. Personal communication, Ron Krumer, Director of External Relations,
Hadassah Hospital Department.
18. Elihu D. Richter, "Richard Horton's 2007 Visit to Gaza and Israel: A
Fool's Journey," http://www.spme.net/cgi-bin/articles.cgi?ID=3455
19. Dr. John Dugard, the former Rapporteur, when confronted with the
information, apologized, but refused to retract these assessments. His
assessments ignored the Kassam rocket attacks on civilian populations and
incitement by the Hamas. Dugard's repeated falsehoods and misrepresentations
raise the question of whether international civil servants should be held to
a level of accountability in keeping with professional norms and standards.
Professor Dugard, by failing to address Palestinian obligations to respect
the human rights of others, Israelis and Palestinians, projects a form of
racism, holding the regime in Gaza to a standard lower than expected from
responsible actors in the international community.
* * *
Professor Elihu D. Richter is head of the Genocide Prevention Program and
Injury Prevention Center, and is the retired head of the occupational and
environmental medicine unit, at Hebrew University-Hadassah School of Public
Health and Community Medicine in Jerusalem. Since the 1980s, he has been
involved in joint projects in epidemiologic research with Palestinian
colleagues on asthma, lead, pesticides, dioxins, and endocrine disrupters.